Arthritis Foundation-funded researcher continues his work with the Arthritis Foundation through the Arthritis Internet Registry.

By Jeanne Erdmann

While pursuing a doctorate in physics, Kaleb Michaud made a hairpin turn in his career path and chose instead to apply his expertise in statistics to rheumatic diseases. Michaud’s decision, boosted with some funding from the Arthritis Foundation, is already making a difference in patients’ lives, not only current patients but future patients as well.

Now an assistant professor at the University of Nebraska, Michaud received a New Investigator grant from the Arthritis Foundation in 2008 to study the impact of total joint replacement in people with rheumatoid arthritis (RA). Even though one out of four people with RA will likely have total joint replacement (TJR), most research on the effects of TJR has been in osteoarthritis (OA) and not RA.

For starters, RA and OA are different diseases. People with RA face a higher risk of infection and cardiovascular problems, which are also two of the complications of TJR surgery. Doctors may worry that replacing damaged joints with their engineered counterparts in RA patients will cost more and worsen recovery.

Answers in Medical Databases

Studying joint replacement in people with RA will help patients understand how well the procedure works and what results patients can expect, such as how much swelling and pain will remain after surgery, how they’ll feel and whether cardiovascular problems or risk of infection will complicate the surgery.

To answer such questions, Michaud and colleagues compared joint replacement in RA and OA in two databases. The National Data Bank for Rheumatic Diseases (NDB) helped the team compare whether people felt better or worse in terms of quality of life and pain. Because the NDB sends out questionnaires every six months to gauge the impact of rheumatic disease, the team could track the personal and financial burden of RA in thousands of patients.

Michaud also examined the electronic medical records of more than 40,000 TJR patients in a Veterans Administration database for outcome data at 30 days and one year. These records allowed him to compare any problems with the surgery between OA and RA, such as infection, mortality and cardiovascular issues.

Most physicians, he says, would expect those issues to be worse in people with RA. Instead, Michaud’s team did not see a boost in risk for complications one month after surgery. At one year, RA patients showed an increase in mortality, but that was due to problems with the disease and not with joint replacement.

In people with OA, the improvement in pain relief proved more dramatic and lasted longer. For people with RA, joint replacement surgery turned back the clock on the replaced joint about three to five years, says Michaud.

Michaud did find an increase in return to the operating room for RA patients while they were in the hospital for joint replacement (4.5 percent for RA as compared to 3 percent for OA patients), although this was balanced by the finding that RA patients were less likely to return to the hospital in the two weeks after the surgery. Overall, he expected a much bigger difference between OA and RA patients.

“This was a welcome surprise,” he says.

While pursuing a doctorate in physics, Kaleb Michaud made a hairpin turn in his career path and chose instead to apply his expertise in statistics to rheumatic diseases. Michaud’s decision, boosted with some funding from the Arthritis Foundation, is already making a difference in patients’ lives, not only current patients but future patients as well.

Now an assistant professor at the University of Nebraska, Michaud received a New Investigator grant from the Arthritis Foundation in 2008 to study the impact of total joint replacement in people with rheumatoid arthritis (RA). Even though one out of four people with RA will likely have total joint replacement (TJR), most research on the effects of TJR has been in osteoarthritis (OA) and not RA.

For starters, RA and OA are different diseases. People with RA face a higher risk of infection and cardiovascular problems, which are also two of the complications of TJR surgery. Doctors may worry that replacing damaged joints with their engineered counterparts in RA patients will cost more and worsen recovery.

Answers in Medical Databases

Studying joint replacement in people with RA will help patients understand how well the procedure works and what results patients can expect, such as how much swelling and pain will remain after surgery, how they’ll feel and whether cardiovascular problems or risk of infection will complicate the surgery.

To answer such questions, Michaud and colleagues compared joint replacement in RA and OA in two databases. The National Data Bank for Rheumatic Diseases (NDB) helped the team compare whether people felt better or worse in terms of quality of life and pain. Because the NDB sends out questionnaires every six months to gauge the impact of rheumatic disease, the team could track the personal and financial burden of RA in thousands of patients.

Michaud also examined the electronic medical records of more than 40,000 TJR patients in a Veterans Administration database for outcome data at 30 days and one year. These records allowed him to compare any problems with the surgery between OA and RA, such as infection, mortality and cardiovascular issues.

Most physicians, he says, would expect those issues to be worse in people with RA. Instead, Michaud’s team did not see a boost in risk for complications one month after surgery. At one year, RA patients showed an increase in mortality, but that was due to problems with the disease and not with joint replacement.

In people with OA, the improvement in pain relief proved more dramatic and lasted longer. For people with RA, joint replacement surgery turned back the clock on the replaced joint about three to five years, says Michaud.

Michaud did find an increase in return to the operating room for RA patients while they were in the hospital for joint replacement (4.5 percent for RA as compared to 3 percent for OA patients), although this was balanced by the finding that RA patients were less likely to return to the hospital in the two weeks after the surgery. Overall, he expected a much bigger difference between OA and RA patients.

“This was a welcome surprise,” he says.

Michaud credits Arthritis Foundation funding for making this project the first of its kind in RA possible. He plans to continue studying the impact of joint replacement in RA. In the meantime, Michaud started a new database called the Arthritis Internet Registry (AIR), a web-based study and social networking opportunity for people with RA and other rheumatic diseases.

“The award from the Arthritis Foundation was crucial in helping me with this study and provided me with the flexibility and time to work on other projects including AIR, which wouldn’t have happened otherwise,” says Michaud.

Walking on “AIR”

AIR was put into motion in 2010. Patients sign up via the Arthritis Foundation website and also provide an optional one-time blood sample. Michaud and Robert Plenge, MD, a geneticist and rheumatologist at Harvard University, got the database up and running and oversee its progress. Michaud credits early, crucial support from John Hardin, MD, vice president of research for the Arthritis Foundation, and E. William St. Clair, MD, president of the American College of Rheumatology’s Research and Education Foundation.

The Arthritis Foundation provides support and advertising through their website. The NDB provided the infrastructure of their website, staff and database for questionnaires; Quest Diagnostics offers free blood draw at their clinics.

Members of AIR answer two questionnaires a year. In turn, the researchers send reports back to patients and follow their progress over time. For example, researchers can compare how certain medications are helping, or whether individual patients do better in winter or summer. Michaud is also working on creating online communities so patients can stay in touch with one another.

Blood samples allow researchers to link blood and genetic markers to each patient, and, in the future, to select family members. These details will help researchers see whether blood profiles and medical experience can shed light on genetic and environmental factors as RA takes its course, help predict disease severity, and even prevent it from ever happening.

“As we do with the NDB, we learn the most from patients themselves. How they’re doing right now is helpful but how they’re doing over the next 10, 15 or 20 years will be so much more helpful. The more we can learn from their experience with their disease, the better,” says Michaud.

AIR researchers aim to make the site interactive and beneficial. Future plans include a medication diary so patients can log when they switch to a new drug. Michaud also wants to include smart phones to track when people experience flares, because such information is usually not recorded.

Frederick Wolfe, MD, a rheumatologist and researcher in Kansas who started the NDB in 1998, has already used data from some of the patients enrolled through the AIR database in his studies of RA and other forms of arthritis.

“This is a very exciting project and it offers an opportunity for patients to participate and for all of us who are studying the outcomes of these illnesses in the broadest sense of the word to benefit from their enrollment,” says Dr. Wolfe.